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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Evaluate neurologic status every 8 hr.

Provide a dark, quiet environment.

Administer magnesium sulfate IV.

Ensure that calcium gluconate is readily available.

Assess respiratory status every 4 hr.

Answer and Explanation

Correct Answer : B,C,D

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.

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Correct Answer is A

Explanation

Explanation:

A. Excessive uterine enlargement

This choice is correct because a hydatidiform mole can cause rapid and excessive growth of the uterus due to the abnormal proliferation of placental tissue. This can lead to the uterus being larger than expected for the gestational age.

B. Profuse, clear vaginal discharge

This choice is not typically associated with a hydatidiform mole. While vaginal discharge can occur during pregnancy, a profuse and clear discharge is not specifically characteristic of a hydatidiform mole. Other causes, such as normal vaginal secretions or infections, could lead to such discharge.

C. Rapid decline in human chorionic gonadotropin (hCG) levels

This choice is not typical of a hydatidiform mole. In fact, one of the hallmarks of a molar pregnancy is an abnormally high level of hCG. The hCG levels may continue to rise instead of declining rapidly.

D. Irregular fetal heart rate

This choice is not associated with a hydatidiform mole because a molar pregnancy does not involve a viable fetus with a heartbeat. Instead, it is characterized by the abnormal growth of placental tissue, which can cause symptoms related to uterine enlargement and complications such as bleeding or preeclampsia, but not an irregular fetal heart rate.

A. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." B. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." C. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week." D. "Exercising during pregnancy is not recommended."

Correct Answer is A

Explanation

Explanation:

A. "Daily jogging for up to 30 minutes is fine throughout the pregnancy."

This response suggests that moderate-intensity exercise like jogging is safe throughout pregnancy. However, it's important to note that individual exercise recommendations can vary based on the woman's health status, pre-pregnancy fitness level, any pregnancy complications, and guidance from her healthcare provider. While moderate exercise is generally encouraged during pregnancy, it's crucial for the client to consult her healthcare provider for personalized recommendations.

B. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester."

This response addresses the importance of avoiding activities that can lead to overheating, such as using saunas or hot tubs, especially during the first trimester when fetal development is particularly sensitive. However, it doesn't specifically address general exercise guidelines.

C. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."

This response suggests a very conservative approach to exercise during pregnancy, focusing primarily on stretching activities. While stretching can be beneficial, it's important for pregnant individuals to engage in a variety of exercises, including aerobic and strength-training activities, as long as they are safe and appropriate for their pregnancy status.

D. "Exercising during pregnancy is not recommended."

This response is not accurate. Exercise during pregnancy is generally recommended and has numerous benefits for both the mother and baby, including improved cardiovascular health, reduced risk of gestational diabetes, enhanced mood, and better overall well-being. However, the type, intensity, and duration of exercise should be tailored to the individual's needs and guided by healthcare providers.

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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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